Care pathways of people aged 75 and over undergoing prolonged hospital stays: a qualitative study using personas and a participatory design approach

Abstract

Population aging and the high prevalence of multimorbidity contribute to the increasing complexity of hospitalized older adults’ care pathways. These pathways, characterized by rapid clinical changes and social and functional needs, make hospital stays more difficult to plan. Prolonged hospital stays among adults aged 75 and over, are associated with functional decline, cognitive deterioration, adverse events, and alternate levels of care placement. A better understanding of these pathways is needed to identify drivers for improvement aligned with the principles of patient-centered design and value-based healthcare. This qualitative study combined a retrospective medical records review and a participatory design approach. In Phase 1, a proportional stratified sample of 100 medical records of adults aged 75 and older experiencing prolonged hospital stays was analyzed. Records were selected from four diagnostic categories most frequently observed among 2,976 older adults in a regional health system in Quebec, Canada. Inductive qualitative content analysis identified dimensions influencing care pathways and informed the development of four representative personas with care pathways and empathy maps. In Phase 2, these personas were used during a World Café workshop involving 101 stakeholders. Participants identified patient needs, vulnerabilities, challenges, and opportunities for improvement before, during, and after hospitalization and co-designed drivers of improvement. The qualitative analysis identified seven dimensions influencing prolonged hospital stays: care transitions, clinical complexity and multimorbidity, functional decline and increasing dependency, psychosocial vulnerabilities, patient and family needs and challenges, family caregiver burden and involvement, and organizational determinants. The personas synthesized care pathway profiles and supported interdisciplinary reflection during the participatory workshop. The World Café highlighted several drivers of improvement, including the integration of a patient navigator, enhanced communication, stronger collaboration with community partners, support for family caregivers, and the development of transitional settings. This study combines qualitative analysis of medical records, persona development, and participatory co-design to examine the care pathways of older adults experiencing prolonged hospital stays. The findings illustrate how empirically grounded personas can support interdisciplinary reflection, facilitate the identification of drivers of improvement, and inform the design of integrated, patient-centred, and value-based care pathways.